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Sunday, February 19, 2012

Evidence-based approaches to
reducing sexual transmission of HIV has remained a major challenge in
responding to the HIV pandemic.
The past 18 months has witnessed a substantial shift in this landscape. Controlled trials have demonstrated that
the treatment of individuals with HIV infection reduces the risk of viral transmission to uninfected sexual
partners (treatment as prevention).
Additional evidence suggests the possibility of providing anti-retroviral
medications to uninfected individuals may reduce the risk of acquiring HIV infection from sexual
partners (PrEP— Pre-Exposure Prophylaxis).

In view of scarce resources, there
will inevitably be a need to prioritize who will get anti-retroviral drugs;
those who are sick, those who can transmit HIV, those at risk for acquiring
HIV. Research that focuses on the balance between efficiency and equity will be
involved. Ethical frameworks for
guiding decision-making at the clinical level as well as the macro social
policy level will be essential.

Among the questions that will need to
be discussed are:

i.What rights claims can uninfected persons make
for access to ARVs for prophylactic purposes when millions across the globe are
dying from AIDS because they cannot access ARV treatment?

ii.What moral claims can justify the provision of
ARV therapy to those who do not yet clinically require treatment as a way of
reducing the risks of HIV transmission?

iii.What normative issues are raised in making the determination
that there is sufficient evidence to demonstrate the effectiveness of either PrEP
or Treatment for Prevention?

iv.How should the social and biological
vulnerability of women to HIV infection inform discussion about the allocations
of resources for either PrEP or treatment as prevention?

v.If there is a risk that PrEP will increase the
risk of drug resistance and compromise treatment options for those already
infected, what ethical questions must be confronted?

vi.What conceptions of procedural fairness and
inclusiveness should shape decision making processes about these allocation
decisions?

vii.How should current research findings inform the
ethics of trial design?

viii.Given current evidence what moral issues
involving the protection of research subjects should be considered in
determining the extent of ancillary services and care that should be provided in
prevention trials?